Healthcare from the perspective of a clinician encompassing both the capture of the clinical viewpoint as well as the technology to help clinicians capture knowledge at the point of care
The thoughts expressed are my own and do not necessarily represent those of Nuance

Tuesday, May 27, 2014

I have the privilege of spending a lot of time on the road interacting with clinicians around the country (and world). I hear with too much frequency many doctors complaining about the Electronic Medical Record and how it fails to help them and in many cases makes their work harder. Some of this is a hangover from the past and the inadequate technology and in some cases hardware at the time
In fact I’ve told this story a number of times that I can date to around 1995/6 and in this piece: Clinical documentation in the EHR

Many years ago, an excited friend who worked for one of the electronic health record (EHR) vendors at that time — it was really more of a billing and patient tracking and management system than an EHR — was desperate to show me some of their latest applications. In particular, a new module they had developed to capture clinical data.
My friend pulled out his laptop, fired up the application, selected a patient and proceeded to enter blood pressure (BP). Some 20-plus clicks later, he had entered a BP of 120/80. While he was excited, I was dumbfounded. When it comes to patient care, doctors didn’t have time for 20 clicks to record BP years ago and they definitely don’t have that luxury in today’s demanding medical environment.

There is still some of that going on and not enough focus on the User Interface design and turning the technology into a barrier - this is the focus of the Art of Medicine campaign we launched some weeks ago

This article on Government HealthIT Are electronic health records already too cluttered? highlights a rising problem and one I hear about frequently. This is not just a healthcare problem and it is the focus of the work by Edward Tufte an American statistician and professor emeritus of political science, statistics, and computer science at Yale University who is well known for his books on information design which are bets acquired by attending one of his frequent courses on data visualization
Here is a recent overview of visualization on the iPhone

He has a section on healthcare but many of his principles apply

For Brian Jacobs the problem was even more acute working in a Pediatric ICU:

The ICU is a very toxic and tech-laden environment….because of that, it offers the opportunity to make a lot of mistakes

As he points out much of the cutter derives form the multiple notes entered into the EHR every day. "It’s not uncommon in teaching hospitals to have six to seven notes per day on one patient, by the time the attending physician, residents, consultants, other doctors and fellows check on the patient."
So they instituted a policy of One Note per day

Actually its

It’s actually one note per team per patient per day; one giant multi-contributor note. They still may be all writing their components, but it’s one note

With a template to hold the content generated each morning by the resident and then everyone contributing to that one note, adding and amending as necessary

So in addressing the issue clutter they also addressed usability and design turning the note into a living breathing document that is updated and maintained by the team that now takes care of patients
But he addressed some other important issues - especially when it comes to quality of care and the quality of the medical note

Copy Forward is subject to some warranted scrutiny from a billing and audit standpoint. Much of the repetitive and “clutter” in the note comes form the copying forward of past information. But:

These notes should never be the same

And as part of that message they moved to an "End-of-day note” that was a fresh summary of the patient.
Add to that an updated and well maintained Problem List and integration with the billing system to allow doctors to select their code for the work carried out that day and they moved to a valuable addition to the healthcare team in delivering quality healthcare with their EHR

EHRs are: more complete, legible, accessible and can be auto-populated and searched. They can provide diagnosis codes and they’re good for billing. On the other hand, they can sometimes lack quality information and are by far, too cluttered.

I said this back in 2003 (yikes!) - The Future of Technology is already here - Who’s on Board the train and who’s left at the station. I still believe it and understand that the technology does need to get better and be more integrated into the existing workflow

The next generation of health care technology is here, with visionaries and futurists pushing the envelope to enhance, create and generate the newest cutting edge in health care delivery. Advances in technology, like advances in medicine, are a shared entity that enhances life expectancy and the quality of life.

In each case, more than 80 percent of respondents indicated they would not be bothered. On a sliding scale, patients indicated the least concern for doctors using tablets during the exam.

What was more surprising was the push back by patients on having scribes

But worst of all - recording devices

Ultimately, over one-third of patients said they’d be bothered by doctors using tape recorders to assist in charting medical notes. Specifically, patients at the furthest end of the spectrum—those who chose “would bother me a lot”—were more prevalent when it came to tape recordings than with any other method of charting during an exam.

There was a big preference to Electronic documentation at the point of care

They asked about reasons for dissatisfaction

Its not the technology that causes the dissatisfaction but in order of importance (for patients)

long wait times at the doctor’s office,

unfriendly staff

short duration of visits with the doctor

Trouble Scheduling Appointment

And coming in with a sliver of dissatisfaction at 5% “Doctor using a Computer in the exam room"